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Polack M, Smit MA, van Pelt GW, Roodvoets AGH, Meershoek-Klein Kranenbarg E, Putter H, Gelderblom H, Crobach ASLP, Terpstra V, Petrushevska G, Gašljević G, Kjær-Frifeldt S, de Cuba EMV, Bulkmans NWJ, Vink GR, Al Dieri R, Tollenaar RAEM, van Krieken JHJM, Mesker WE. Results from the UNITED study: a multicenter study validating the prognostic effect of the tumor-stroma ratio in colon cancer. ESMO Open 2024; 9:102988. [PMID: 38613913 PMCID: PMC11033069 DOI: 10.1016/j.esmoop.2024.102988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND The TNM (tumor-node-metastasis) Evaluation Committee of Union for International Cancer Control (UICC) and College of American Pathologists (CAP) recommended to prospectively validate the cost-effective and robust tumor-stroma ratio (TSR) as an independent prognostic parameter, since high intratumor stromal percentages have previously predicted poor patient-related outcomes. PATIENTS AND METHODS The 'Uniform Noting for International application of Tumor-stroma ratio as Easy Diagnostic tool' (UNITED) study enrolled patients in 27 participating centers in 12 countries worldwide. The TSR, categorized as stroma-high (>50%) or stroma-low (≤50%), was scored through standardized microscopic assessment by certified pathologists, and effect on disease-free survival (DFS) was evaluated with 3-year median follow-up. Secondary endpoints were benefit assessment of adjuvant chemotherapy (ACT) and overall survival (OS). RESULTS A total of 1537 patients were included, with 1388 eligible stage II/III patients curatively operated between 2015 and 2021. DFS was significantly shorter in stroma-high (n = 428) than in stroma-low patients (n = 960) (3-year rates 70% versus 83%; P < 0.001). In multivariate analysis, TSR remained an independent prognosticator for DFS (P < 0.001, hazard ratio 1.49, 95% confidence interval 1.17-1.90). As secondary outcome, DFS was also worse in stage II and III stroma-high patients despite adjuvant treatment (3-year rates stage II 73% versus 92% and stage III 66% versus 80%; P = 0.008 and P = 0.011, respectively). In stage II patients not receiving ACT (n = 322), the TSR outperformed the American Society of Clinical Oncology (ASCO) criteria in identifying patients at risk of events (event rate 21% versus 9%), with a higher discriminatory 3-year DFS rate (stroma-high 80% versus ASCO high risk 91%). A trend toward worse 5-year OS in stroma-high was noticeable (74% versus 83% stroma-low; P = 0.102). CONCLUSION The multicenter UNITED study unequivocally validates the TSR as an independent prognosticator, confirming worse outcomes in stroma-high patients. The TSR improved current selection criteria for patients at risk of events, and stroma-high patients potentially experienced chemotherapy resistance. TSR implementation in pathology diagnostics and international guidelines is highly recommended as aid in personalized treatment.
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Affiliation(s)
- M Polack
- Department of Surgery, Leiden University Medical Center, Leiden
| | - M A Smit
- Department of Surgery, Leiden University Medical Center, Leiden
| | - G W van Pelt
- Department of Surgery, Leiden University Medical Center, Leiden
| | - A G H Roodvoets
- Clinical Research Center, Department of Surgery, Leiden University Medical Center, Leiden
| | | | - H Putter
- Department of Biomedical Data Sciences, Leiden
| | | | - A S L P Crobach
- Department of Pathology, Leiden University Medical Center, Leiden
| | - V Terpstra
- Department of Pathology, Haaglanden Medical Center, The Hague, The Netherlands
| | - G Petrushevska
- Department of Pathology, Medical Faculty of Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
| | - G Gašljević
- Department of Pathology, Onkološki inštitut-Institute of Oncology, Ljubljana, Slovenia
| | - S Kjær-Frifeldt
- Department of Pathology, Vejle Sygehus-Sygehus Lillebælt, Vejle, Denmark
| | | | | | - G R Vink
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - R Al Dieri
- European Society of Pathology, Brussels, Belgium
| | | | - J H J M van Krieken
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W E Mesker
- Department of Surgery, Leiden University Medical Center, Leiden.
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Dijkstra EA, Zwart WH, Nilsson PJ, Putter H, Roodvoets AGH, Meershoek-Klein Kranenbarg E, Frödin JE, Nygren P, Østergaard L, Kersten C, Verbiené I, Cervantes A, Hendriks MP, Capdevila J, Edhemovic I, van de Velde CJH, Marijnen CAM, van Etten B, Hospers GAP, Glimelius B. The value of post-operative chemotherapy after chemoradiotherapy in patients with high-risk locally advanced rectal cancer-results from the RAPIDO trial. ESMO Open 2023; 8:101158. [PMID: 36871393 PMCID: PMC10163161 DOI: 10.1016/j.esmoop.2023.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Pre-operative chemoradiotherapy (CRT) rather than radiotherapy (RT) has resulted in fewer locoregional recurrences (LRRs), but no decrease in distant metastasis (DM) rate for patients with locally advanced rectal cancer (LARC). In many countries, patients receive post-operative chemotherapy (pCT) to improve oncological outcomes. We investigated the value of pCT after pre-operative CRT in the RAPIDO trial. PATIENTS AND METHODS Patients were randomised between experimental (short-course RT, chemotherapy and surgery) and standard-of-care treatment (CRT, surgery and pCT depending on hospital policy). In this substudy, we compared curatively resected patients from the standard-of-care group who received pCT (pCT+ group) with those who did not (pCT- group). Subsequently, patients from the pCT+ group who received at least 75% of the prescribed chemotherapy cycles (pCT ≥75% group) were compared with patients who did not receive pCT (pCT-/- group). By propensity score stratification (PSS), we adjusted for the following unbalanced confounders: age, clinical extramural vascular invasion, distance to the anal verge, ypT stage, ypN stage, residual tumour, serious adverse event (SAE) and/or readmission within 6 weeks after surgery and SAE related to pre-operative CRT. Cumulative probability of disease-free survival (DFS), DM, LRR and overall survival (OS) was analysed by Cox regression. RESULTS In total, 396/452 patients had a curative resection. The number of patients in the pCT+, pCT >75%, pCT- and pCT-/- groups was 184, 112, 154 and 149, respectively. The PSS-adjusted analyses for all endpoints demonstrated hazard ratios between approximately 0.7 and 0.8 (pCT+ versus pCT-), and 0.5 and 0.8 (pCT ≥75% versus pCT-/-). However, all 95% confidence intervals included 1. CONCLUSIONS These data suggest a benefit of pCT after pre-operative CRT for patients with high-risk LARC, with approximately 20%-25% improvement in DFS and OS and 20%-25% risk reductions in DM and LRR. Compliance with pCT additionally reduces or improves all endpoints by 10%-20%. However, differences are not statistically significant.
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Affiliation(s)
- E A Dijkstra
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - W H Zwart
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - P J Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - H Putter
- Departments of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - A G H Roodvoets
- Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - J E Frödin
- Department of Oncology-Pathology, Karolinska University Hospital, Uppsala
| | - P Nygren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - L Østergaard
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - C Kersten
- Department of Research, Sørlandet Hospital Trust, Kristiansand, Norway
| | - I Verbiené
- Department of Oncology, Uppsala University, Uppsala, Sweden
| | - A Cervantes
- Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - M P Hendriks
- Department of Medical Oncology, Northwest Clinics, Alkmaar, the Netherlands
| | - J Capdevila
- Department of Medical Oncology, Vall Hebron Institute of Oncology (VHIO), Vall Hebron University Hospital. Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - I Edhemovic
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - C J H van de Velde
- Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam; Department of Radiation Oncology, Leiden University Medical Center, Leiden
| | - B van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G A P Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Breugom AJ, van Gijn W, Muller EW, Berglund Å, van den Broek CBM, Fokstuen T, Gelderblom H, Kapiteijn E, Leer JWH, Marijnen CAM, Martijn H, Meershoek-Klein Kranenbarg E, Nagtegaal ID, Påhlman L, Punt CJA, Putter H, Roodvoets AGH, Rutten HJT, Steup WH, Glimelius B, van de Velde CJH. Adjuvant chemotherapy for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial. Ann Oncol 2014; 26:696-701. [PMID: 25480874 DOI: 10.1093/annonc/mdu560] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The discussion on the role of adjuvant chemotherapy for rectal cancer patients treated according to current guidelines is still ongoing. A multicentre, randomized phase III trial, PROCTOR-SCRIPT, was conducted to compare adjuvant chemotherapy with observation for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision (TME). PATIENTS AND METHODS The PROCTOR-SCRIPT trial recruited patients from 52 hospitals. Patients with histologically proven stage II or III rectal adenocarcinoma were randomly assigned (1:1) to observation or adjuvant chemotherapy after preoperative (chemo)radiotherapy and TME. Radiotherapy consisted of 5 × 5 Gy. Chemoradiotherapy consisted of 25 × 1.8-2 Gy combined with 5-FU-based chemotherapy. Adjuvant chemotherapy consisted of 5-FU/LV (PROCTOR) or eight courses capecitabine (SCRIPT). Randomization was based on permuted blocks of six, stratified according to centre, residual tumour, time between last irradiation and surgery, and preoperative treatment. The primary end point was overall survival. RESULTS Of 470 enrolled patients, 437 were eligible. The trial closed prematurely because of slow patient accrual. Patients were randomly assigned to observation (n = 221) or adjuvant chemotherapy (n = 216). After a median follow-up of 5.0 years, 5-year overall survival was 79.2% in the observation group and 80.4% in the chemotherapy group [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.62-1.39; P = 0.73]. The HR for disease-free survival was 0.80 (95% CI 0.60-1.07; P = 0.13). Five-year cumulative incidence for locoregional recurrences was 7.8% in both groups. Five-year cumulative incidence for distant recurrences was 38.5% and 34.7%, respectively (P = 0.39). CONCLUSION The PROCTOR-SCRIPT trial could not demonstrate a significant benefit of adjuvant chemotherapy with fluoropyrimidine monotherapy after preoperative (chemo)radiotherapy and TME on overall survival, disease-free survival, and recurrence rate. However, this trial did not complete planned accrual. REGISTRATION NUMBER Dutch Colorectal Cancer group, CKTO 2003-16, ISRCTN36266738.
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Affiliation(s)
- A J Breugom
- Department of Surgery, Leiden University Medical Centre, Leiden
| | - W van Gijn
- Department of Surgery, Leiden University Medical Centre, Leiden
| | - E W Muller
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - Å Berglund
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala
| | | | - T Fokstuen
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - H Gelderblom
- Department of Clinical Oncology, Leiden University Medical Centre, Leiden
| | - E Kapiteijn
- Department of Clinical Oncology, Leiden University Medical Centre, Leiden
| | - J W H Leer
- Department of Radiotherapy, Radboud University Medical Centre, Nijmegen
| | - C A M Marijnen
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - H Martijn
- Department of Radiotherapy, Catharina Hospital, Eindhoven
| | | | - I D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L Påhlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - C J A Punt
- Department of Medical Oncology, Academic Medical Centre, Amsterdam
| | - H Putter
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Centre, Leiden
| | - A G H Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven
| | - W H Steup
- Department of Surgery, HAGA Hospital, The Hague, The Netherlands
| | - B Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala; Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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